Broadwell Christian Hospital (BCH) is located in Fatehpur town of Fatehpur district, Uttar Pradesh. A national survey in 2011 identified Fatehpur as one of the backward districts of Uttar Pradesh. Missionaries from Canada saw that the region lacked health infrastructure, and in response, they established this hospital in 1907 which has been caring for the community, especially its women and children, since then. The hospital provides basic health services and through its community health team does outreach work in many parts of the district.

The community health team works comprehensively with communities in the urban slums around the town that it had identified as extremely poor. These communities comprise of clusters of people belonging to economically backward castes and groups. Living in “slums” or “Malin Bastis,” they had been ignored by the municipality for at least 50 years. The team initially identified 15 such groups of people and later 25 more among 36 slums, contributing to a total population of 25,000 people. Although located within the urban township, the people in these pockets lived in unhygienic environments, and had poor, or sometimes no, access to health care. They predominantly belonged to the “dalit” and other backward castes and worked as manual laborers, rickshaw pullers, vegetable sellers, etc.

While with the coming of the National Rural Health Mission, the infrastructure in rural villages grew, that in urban slums did not as there was no urban health mission and they were left out of the health and development plans.

Community Vision Building

In 2011, the community health team began organizing and mobilizing these communities to access health-care services and other development needs. As vision building exercises, communities were encouraged to get together and dream for their future. They reflected on their troubles and wished for a better life. They dreamt of healthy children and good schooling. They wished for good places to live in with clean water and good roads. This built up their hopes and desires. Using that, we encouraged them and taught them that with commitment, teamwork, and persistence, what they dreamt of was possible. We encouraged them to form leadership teams toward this. Thus, community action groups were formed to analyze and solve their own problems.

People learned about their rights. They learned how to approach the government and they were empowered to apply to the government for better roads, electricity, and water systems. Fifteen such committees which have been created are active today. They have prioritized addressing issues of health and development in the urban slums. They have lobbied with the municipality and the district magistrate for their entitlements. They have given several applications to the authorities for clean water, roadways, and electricity. They have managed to capture the attention of the media and district authorities. They have been successful. Due to their work, several hand pumps have been installed, roadways have been repaired, and slums have been electrified. We have compiled and presented some of these stories of success, including access to health care, immunization, and hospitalized deliveries. The data presented here show the marked difference [Table 1].

Table 1: Summary of Reproductive and Child Health indicators from 2011 to 2014

Mr. Kisan* was not interested in contributing to the health-care committee initially, because he is physically limited with a disability and people in his slum expected very little of him. During a visit, the BCH staff noticed that he could express his thoughts very well. On our team's suggestion, he became a part of the Adharpur health care committee (HCC) and began contributing positively to the community.

The government runs a health insurance scheme called Rastriya Swasthya Bima Yojana (RSBY), During its enrollment process, Mr. Kisan demonstrated what self-confidence can do. He proved that despite his physical challenges, he could be useful to the people around him. He went from door-to-door informing people of the date and of the things necessary to enroll into the scheme. Because of his efforts, many families from Adharpur could avail the benefits of the scheme. Now, anyone with a card who falls sick in the slum thanks him. They are grateful because otherwise they would have had to pay much of their hard-earned money on treatment.

Story 2: United we Stand; Divided we Fall: The Story of Khalifapur

Khalifapur is a slum about 4 km away from the main bus stand of the district headquarters. It came to be due to the migration of people from the nearby villages and the town of Fatehpur. However, its roads are in a sorry state. The slum resembles a village with its mud-walled and thatched-roofed houses and its civic facilities are scarce. However, the people have become indifferent to the problems around them.

We found a few people who, after guidance, agreed to work together. Thus, a committee was formed. We regularly visited them to ensure that at least a few people met, gave their time to understand their problems, and were willing to contribute to change.

Although Khalifapur has been under the authority of the municipality since 1968, it is receives no attention from the authorities in terms of development. As part of our project activities, the people of Khalifapur put in their applications for better roads, drinking water, drainage, and electricity. However, the efforts that went into make and submit these applications seemed fruitless; nobody really bothered about the condition of the village.

Meanwhile, Khalifapur lay barren-like desert land with no rain. The community health team started praying for these areas and found their prayers for rains answered. This caused a sudden awakening in the people. They were motivated to unite and take action, as they felt God had graced and empowered them. God, they felt, had chosen the project to light their way.

They took an application, which was based on action plans they had made during this time, to the media. Although it was published, it did not have much of an impact. They, then, met with the local leader who offered his support. The BCH staff advocated action, and as a result, the community made efforts to present their problems to the district administration. They held peaceful demonstrations in front of the office of the District Magistrate (DM) and the Subdivisional Magistrate (SDM) responded by coming forward to receive their applications for better roads, safe drinking water, good drainages, and electricity [Figure 1] and [Figure 2].

The local media in Fatehpur highlighted this, causing the government authorities to investigate the matter. The DM, SDM, and EO visited the villages personally and saw its condition. Following this resulted the construction of the roads and drainages in the village commenced. For drinking water, the local representative and the municipality promised to install hand pumps in the slums.

The district administration requested the Nagar Palika (town municipality) to report to them all the details of expenditure on development for the whole year. The village Chairman gave a media interview regarding the problems in his village. Following this, the media started highlighting other issues of sanitation in the nearby project areas as well.

Story 3: The Story of Jairampur

Jairampur is a slum under the town municipality. It has existed since 1960 but saw no further developments. During the rainy season, the potholes in the roads filled up with water. There had been incidents of children and elderly persons who fell into them while walking on these. After a BCH project, the CHDP intervened in Jairampur and a HCC was formed. The committee and organized community programs to bring up and address their problems, including the state of their roads and drainages.

They organized a meeting with the Sabhasad, project staff to discuss these problems. Based on the decision taken in this meeting, an application detailing the problem was written and submitted to the local authorities. Nothing, however, was done.

The committee then went to meet the Chairman of the Nagar Palika. However, he was not available and their application had to be submitted to his peon. Once more, nothing was done. After a month, they managed to meet the Chairman who promised that work will be done. However, once more, nothing happened. The committee did not give up. Every month, they submitted their applications to the District Magistrate, Additional District Magistrate, and Member of Legislative Assembly.

The government officials were forced by their persistence to visit the slum and see its condition. Soon proposals for developing the roads and drainages were passed and on the February 15, 2014, work began. On being persuaded by the committee members, people in the slum permitted their illegally constructed walls, to be broken by the contractors, and thereby, cooperated with the officials.

Thus was formed a slogan in the village-

“Der Hua Durust Hua Ekta mein hi bal hain”

It means “It happened later; happened for the better. There is strength in unity.” This is what they believe about their Samiti (Committee).

Health with Gender Participation

The team discovered that Reproductive and Child Health education is more effective when delivered to couples since both the husband and wife were empowered with the information to make good decisions about issues such as immunization, family planning, and birth planning. Usually, community-level interventions take place in women's meetings and forums. The man is left out of the learning when he, in reality, he is the decision-maker. This places several constraints on the woman who cannot make these decisions, especially when her husband does not understand what she was taught. When they are both present, they can learn and make decisions together. This was the beginning of gender transformative processes in the family.

Understanding Social Determinants of Health

Working with the community at a sociological level helped us understand that their problems were very deep-rooted and that to empower them adequately, transformation was necessary in many domains of their lives. Belonging to the “backward caste” caused them to have poor self-esteems and centuries of suppression made them fatalistic. They continued to live in the trap of poverty. The team also observed that the gender dynamics in the communities limited their growth and development. Several atrocities against women, including rape, happened there. Sad stories existed in the community young girl being gang raped by teenage boys. The victims preferred not to report it and their parents were too afraid of the community to take legal action. Domestic violence was also rampant and patriarchal control limited women significantly.

Changes in Gender Views

The central government had established a Family Counseling Center in the district and fast-track courts were held every month as part of the legislative systems. Dr. Sunitha visited government offices to identify the point persons for violence and gender issues. However, women did not use these resources much because of their fear and ignorance. The BCH team researched about gender sensitization and intervention in detail and team sought to improve the community's awareness on gender-related issues. This led to an increase in the number of discussions and debates in the communities. Here, we understood the patriarchal views both men and women held that women had lower positions in society and that men had the right to abuse their wives. We realized that a community level intervention would be controversial. Hence, we introduced interventions with smaller groups. Since we were successful working with couples for health, we tried working with them on gender-related issues as well. We hosted common meetings with one couple from each community meeting at BCH for joint sessions. Follow-up visits at home revealed that violence against the woman had reduced. We, then, tried to upscale this by hosting community-based couple workshops consisting of eight sessions with eight to ten couples from each locality. Follow-up interviews revealed that the family dynamics had improved. Where conflict was difficult to resolve, we found it useful to approach the Family Counseling Center of the government.

Gender and Women Empowerment Women

Empowerment is a broad term and sometimes it is possible to deceive ourselves within the framework of activities. Eight Muslim women, who were members of their village committee, decided to address their issue of lack of drinking water. They went to the DM and submitted their request for a new hand pump. Their request was granted not a long time. However, in a community where women are restrained from making decisions, this picture of them walking to claim their right is a refreshing sight [Figure 3].

A very busy village, engaged in gambling, and in brewing and selling illegal liquor, lacked electricity. The children and women, who were usually the only sober ones in the village, decided to change it. They went to the DM office carrying placards, demanding their right to electricity. Although it did not yield much result, the initiative is very commendable.

Spreading awareness about help available for women victims has been an important aspect of our work. Neelam* married a rich businessman in Delhi in 2014. Barely 20-year old, she was treated badly within days of her marriage. She was locked up, beaten, and denied food. Her life was nothing short of horror. One day, she approached the police. However, nothing resolved and the violence persisted. She, then, left him and returned to her parents' house in Fatehpur. Acting on the advice of the project staff, Neelam registered her complaint with the probation officer in Fatehpur and refrained from going back to her husband's house.

Valuing the opinions of daughters and not forcing them to do things against their wishes were topics we discussed. As a result, the parents of a girl allowed her to marry the person of her choice. This was against the traditional custom of an arranged, or worse still, a forced marriage. However, to avoid social stigma, her family took her to the temple and she got her married secretly as they did not want the village folk to know.

Girls are not considered a joy like boys are. Although there are laws against female feticide, the practice still exists in the parts of rural India. In the Gehar basti, a slum of gypsy tribes, one man decided not to abort his wife's pregnancy after learning the ill-effects of unnecessary abortions in a couples' workshop session. He also decided to accept the baby whatever sex it belonged to.

It is not unusual for women to sit on the floor and men to sit on the chairs that are available. A man after attending the first session of the couples' workshop, went back to get his wife for the second session, as he wanted her to participate also. Along with her, he brought a chair for her, saying that women are no less valuable than men to have to sit on the floor. In a culture where women are subdued in every form, this little act shows the impact of the couples' workshop on the attitudes of men.

Remolding the Next Generation

The future of the community is its children. To see change tomorrow, we must work with the young today. To address social issues, we must deal with the issues of personality and esteem among them. With this in mind, our community health team organized for groups of adolescent boys and adolescent girls to meet and discuss issues that relate to their identities, purposes in life, and their skills. The first topic discussed was “Who am I? I am fearfully and wonderfully made.” The discussion brought light to their eyes. The girls realized their value and the worth of their lives. The adolescents began seeing the worth of themselves and others. They also identified that people with disabilities were individuals like themselves. They resolved not call them names such as “hey you blind one” or “hey you crippled one” (Eh andhaa, eh langadaa) and instead to call them by their first names.

The issue of gender equality was also introduced in these groups. Sexual experimentation, refusal skills, child sexual abuse, opposite-sex friendships, and the sacredness of marriage were discussed openly and in a nonjudgmental way. Conflict resolution and the use of violence to resolve conflict were also discussed. The boys groups also discussed effects of pornography and addiction in their lives. Initially, parents were suspicious about the intentions behind these groups. Hence, we invited them to join a session, to silently observe for themselves. In a few month times, having seen their children change, they supported and encouraged them to attend the discussions. Today, we have 25 such groups, each with at least 15 children.

Stories from Adolescent Work

Nisha*, when studying in class 11, was being pursued by a boy who was introduced to her by a friend. Her friend tried to persuade her to accept his “love.” The boy tried approaching her on the road near the school, etc., She changed her school to get rid of his advances. But when nothing worked, she told her mom about him. She refused to give in to his pressures because of the refusal skills she learned in the group.

Seema* had gone to her neighbor's house to charge her mobile phone. The neighbors' son was also in his teens. The neighbors except for the son were away during her visit. During this time, the son started talking to her and within a few minutes turned sexually provocative. In the session on sexual experimentation, skills on refusing sexual advancements had been imparted. Seema used these skills, left immediately, went home and reported the incident to her mother. Their families debated it until the boy, ultimately, left the locality and went away.

Radha* had learned about keeping good friendships and about not indulging in sexual experimentation. She noticed that her friend mingled excessively with a married man who, over time, disturbed her. She called her friend aside and advised her to refrain from seeing him. She also had the courage to talk to that man, discouraging him from continuing. This helped and prevented her friend from falling into any major problems.

Girls were being harassed by a shopkeeper boy whenever they went to his shop to buy things. One day, in the adolescent meeting, the girls decided to do something about it. They went as a group and one of them went to the boy in the pretext of purchasing something. The boy, as usual, misbehaved with her. The rest of the group who were waiting some distance away came to the shop when they saw the misbehavior and threatened to “deal with” him if he persisted in his actions. The boy left the shop and was never seen thereafter.

Moni* learned the difference between “good touch” and “bad touch” in one of the adolescent sessions. When one man from her village tried to touch her inappropriately, she reported it to her mother. In a society where any such incidents are hushed up, by speaking up, Moni helped counter abuse and violence.

Neelu* was fixed to marry a man. She was just finishing her teens and he was several years older than her. She realized that it would not work well for her and refused to marry him. In one of the adolescent meetings, she spoke about this struggle. The group advised her to convince her parents, following which she spoke to them. After a few months, she consented to call off the marriage. Now, her parents consult her every time a proposal comes. Children do not have much of a say in decisions regarding their own marriage. The adolescent meetings really helped parents and children connect over these critical decisions.